Professionals are frequently required to document events that they have observed or in which they are participants. Depending on the situation and the circumstances, the documentation may all be created contemporaneously with the event, or it may be prepared later from notes or it may be dictated and transcribed. Typically, it is the responsibility of the professional to personally attest to the accuracy and completeness of the completed documents. Furthermore, it is typically the responsibility of the custodian of these documents to ensure their integrity.
For example, it is common in the healthcare field to combine contemporaneous and deferred documentation. In this instances the health care professional is ultimately responsible for attesting to the accuracy, completeness and authenticity of every document entered into a patient's medical record. Law enforcement and other professions involving inspection or oversight have a similar responsibility to produce credible contemporaneous documentation for good record management as well as to prevent or defend against claims of liability or violations of law.
As event documentation has become ever more detailed and complex, the need for automated processes for collecting, storing, transmitting, and retrieving information becomes more critical. Historically, hand-entered records are very brief and sometimes of limited value for future use, either because entries were illegible, used non-standard abbreviations, lacked sufficient detail, or were difficult to search. Because of the shortcomings of the paper-based record, electronic record management systems have been investigated for a number of years. Current electronic record management systems provide some advantages over traditional hard-copy records, but have not been widely adopted by the professional community.
Current attempts to develop database architectures capable of storing and retrieving medical record information have failed to reconcile user desires for maintaining a format of unstructured information with database requirements for highly structured data storage. In addition, voice recognition systems capable of generating text from human speech address the area of dictation but offer few improvements in the organization and management of event documentation.